A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model

May combine two claims.

Mice with a removed learning gene, when exposed to an enriched environment, showed epigenetic changes that enhanced learning despite the genetic defect, and their offspring did too.

“when mice who had a gene that supports the ability to learn removed, and were then exposed to an enriched environment containing elevated social interactions, novel objects, and voluntary exercise, not only did they show epigenetic changes leading to an enhanced ability to learn despite their genetic defect, so too did their offspring (Arai, Li, Hartley, & Feig, 2009).”

• cites Arai, Li, Hartley, & Feig, 2009Not checked yet

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May combine two claims.

Selecting foxes for tameness over decades also produces floppy ears, showing that selection on juvenile behavioral traits can bring juvenile anatomical traits with it.

“several decades of breeding foxes to be more tame also results in the floppy ears that are often characteristic of domesticated animals -- it turns out that selecting for juvenile behavioral traits, such as tameness, brings juvenile anatomical traits along for the ride (Trut, 1999).”

• cites Trut, 1999 sourceNot checked yet

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May combine two claims.

Epidemiologic and clinical studies show very high comorbidity among DSM disorders, which undermines the idea that syndromes represent distinct etiologies.

“Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies.”

• cites Kupfer, First, & Regier, 2002Not checked yet

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May combine two claims.

Full genomic analyses sometimes find cumulatively meaningful genetic risk factors, but these involve hundreds or thousands of alleles whose functions are often unknown.

“Studies with full genomic analyses of tens or even hundreds of thousands of participants sometimes identify cumulatively meaningful genetic risk factors, but they involve hundreds if not thousands of alleles, the specific functions of which are often not understood (Crespi, 2020; Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013).”

• cites Crespi, 2020 sourceNot checked yet

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• cites Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013 sourceNot checked yet

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May combine two claims.

Environmental events and accompanying psychological functions can cause epigenetic changes that alter gene expression and can produce long-term changes within an individual and sometimes across generations.

“Environmental events and their accompanying psychological functions can lead to epigenetic changes (e.g., methylation of cytosine; histone bundling) that alter gene expression, and can lead not just to long-term changes in traits within an individual, but sometimes to changes in later generations and eventually to genetic accommodation (Jablonka & Lamb, 2014).”

• cites Jablonka & Lamb, 2014Not checked yet

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Probably not a substantial claim: may not pass S4 (based).

For fifty years, psychotherapy research has mainly pursued syndrome-specific protocols for supposed latent disease entities defined by psychiatric nosology.

“For half a century, the dominant paradigm in psychotherapy research has been to develop syndrome-specific treatment protocols for hypothesized but unproved latent disease entities, as defined by psychiatric nosological systems.”

May combine two claims.

The syndromal approach gave mental health a shared language but did not achieve conceptual or treatment utility.

“While this approach provided a common language for mental health problems, it failed to achieve its ultimate goal of conceptual and treatment utility.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

There are already hundreds of processes of change, which overwhelms practitioners who might apply them.

“There are already hundreds of such processes, overwhelming any practitioner who may be interested in applying them.”

Probably not a substantial claim: may not pass S2 (checkable).

Processes of change by themselves cannot produce a coherent diagnostic system; they must be organized.

“Processes of change alone cannot lead to a coherent diagnostic system: they must be organized.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

A multi-dimensional, multi-level extended evolutionary meta-model provides consilience and a shared language for process-based diagnosis.

“We argue that a multi-dimensional, multi-level extended evolutionary meta-model (EEMM) provides consilience and a common language for process-based diagnosis.”

Probably not a substantial claim: may not pass S4 (based).

A syndromal model has driven psychiatric nosology for fifty years.

“For half a century, a syndromal model has driven psychiatric nosology.”

Probably not a substantial claim: may not pass S4 (based).

The EEMM applies evolutionary concepts of context-appropriate variation, selection, and retention to biopsychosocial dimensions and levels tied to suffering, problems, and positive functioning.

“The EEMM applies the evolutionary concepts of context-appropriate variation, selection, and retention to key biopsychosocial dimensions and levels related to human suffering, problems, and positive functioning.”

Probably not a substantial claim: may not pass S4 (based).

The EEMM is a meta-model for diagnosis and intervention that can include any evidence-based change processes regardless of therapy orientation.

“The EEMM is a meta-model of diagnostic and intervention approaches that can accommodate any set of evidence-based change processes, regardless of the specific therapy orientation.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Evolutionary principles are the most widely used concepts for understanding how complex systems develop in the life sciences.

“Evolutionary principles are the most widely used concepts when seeking to understand how complex systems. develop in the life sciences.”

May combine two claims.

Hundreds of studies on mediators of clinical outcomes now exist, making them a strategic starting point for a diagnostic system.

“Yet, we can begin a diagnostic system with known mediators of importance because, unlike forty years ago when syndromal diagnosis first captured the field, hundreds of studies now exist on the mediators of clinical outcomes.”

May combine two claims.

The hope that behavioral genetics would quickly identify specific psychiatric diseases has been replaced by relative certainty that it will not, leading to a refocus on psychological phenotypes.

“The hope that behavioral genetics would rapidly lead to the identification of specific psychiatric diseases has been replaced by the relative certainty that this will not happen, leading to a healthy refocusing of the field toward aspects of psychological phenotypes rather than “disorders” per se.”

May combine two claims.

Physical attractiveness is one of the most powerful demographic variables known to science and is substantially genetic.

“Physical attractiveness is one of the most powerful demographic variables known to science (Langlois et al., 2000), and it is substantially genetic (Gangestad & Scheyd, 2005).”

• cites Langlois et al., 2000 sourceNot checked yet

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• cites Gangestad & Scheyd, 2005Not checked yet

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May combine two claims.

The failure to answer Paul's question is unsurprising because the field turned toward an alliance between syndromal academic psychiatry and intervention science, focusing on protocols for diagnostic entities in randomized trials.

“This failure is not surprising because the field’s attention was soon directed elsewhere. As an alliance formed between a syndromal approach in academic psychiatry and the intervention science of empirical clinical psychology, research increasingly focused on the impact of treatment protocols on the signs and symptoms of diagnostic entities as examined in randomized controlled trials.”

May combine two claims.

Mediators often have bidirectional and complex relationships that vary across individuals.

“Mediators often form bi-directional and complex relationships that differ between individuals (Hofmann, Curtiss, & Hayes, 2020).”

• cites Hofmann, Curtiss, & Hayes, 2020 sourceNot checked yet

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May combine two claims.

Context is key to diagnosis and treatment because no psychological attribute is always useful.

“Context is key to diagnosis and treatment because no psychological attribute is always useful.”

May combine two claims.

A field-wide consensus began to build for more clarity about philosophical assumptions, greater understanding of processes of change, increased focus on fitting interventions to individuals, and greater emphasis on competency in delivering helpful intervention kernels rather than trademark protocols.

“A field-wide consensus began to build (Klepac et al., 2012) for more clarity about philosophical assumptions; greater understanding of processes of change (Kazdin, 2007); an increased focus on fitting intervention methods to the needs of individuals (Ng & Weisz, 2016); and a greater emphasis on competency in delivering a wide variety of helpful inventions kernels (Weisz, Ugueto, Herren, Afienko, &”

• cites Klepac et al., 2012 sourceNot checked yet

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• cites Kazdin, 2007 sourceNot checked yet

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• cites Ng & Weisz, 2016 sourceNot checked yet

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Classified as probably not a substantial claim.

Even as the field moved toward processes of change, an overarching theory was needed to avoid a cacophony of constructs.

“Even as the field moved toward processes of change, however, it was clear that an overarching theory would be needed to avoid a cacophony of constructs (Goldfried, 2009).”

• cites Goldfried, 2009 sourceNot checked yet

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May combine two claims.

The six psychological dimensions are not discrete or an ultimate irreducible set, but they capture the dimensions most commonly emphasized and measured in clinical models.

“We are not arguing that these psychological dimensions are discrete, or form an ultimate, irreducible set; but that they capture the dimensions most commonly emphasized and measured in clinical models.”

Probably not a substantial claim: may not pass S4 (based).

Maladaptation occurs because of problems in any of the variation, selection, or retention systems.

“Maladaptation occurs because of problems in any of these systems.”

May combine two claims.

This possibility has been hindered by RDoC's reductionistic and biocentric application, its continued search for latent diseases, and its treatment of change processes as ergodic.

“But this possibility has beebn hindered by RDoC’s reductionistic, biocentric application, by the continued search for latent diseases, and by the treatment of change processes as ergodic phenomena.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Processes of variation, selection, retention, and context apply to all inheritance streams or dimensions.

“These processes of variation, selection, retention and context apply to all inheritance streams or dimensions.”

May combine two claims.

The psychological level is nested with the sociocultural level of group behavior and cultural practices, and the psychological level contains a genetic/physiological level and other life forms.

“The psychological level is thus nested with the sociocultural level of group behavior and cultural practices (Wilson & Coan, 2020), but the psychological level in turn contains a genetic/physiological level -- genes, epigenes, brain circuits, organ systems, and so on -- and the other life forms contained within.”

• cites Wilson & Coan, 2020Not checked yet

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Probably not a substantial claim: may not pass S4 (based).

Mental health funding agencies are challenging researchers to identify functionally important processes of pathology and change.

“Instead, researchers are being challenged by mental health funding agencies to identify functionally important processes of pathology and change.”

Classified as probably not a substantial claim.

RDoC called for exploring different units of analysis across multiple levels to identify processes that might lead to psychopathology.

“RDoC called for researchers to explore different units of analysis (e.g., positive and negative motivational systems) across various levels of analysis (e.g., molecular, brain circuit, behavioral, cultural, and symptom level) to identify processes that might lead to psychopathology.”

May combine two claims.

Context determines selection pressures over particular phenotypes, and becomes a focus of conscious attention when the goal is intentional evolutionary change.

“It is context that determines selection pressures over particular phenotypes, but it becomes a particular focus of conscious attention when the goal is intentional evolutionary change.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Retention is key to any prosocial change, and psychotherapy addresses retention through maintenance at follow-up, homework, reinforcement of skill practice, and development of health habits.

“Retention is key to any prosocial change, and psychotherapy is used to these issues in the form of maintenance at follow up, the use of homework, the reinforcement of skill practice, or the development of health habits.”

Classified as probably not a substantial claim.

The qualitative research approach lacked the experimental methods needed to produce a systematic, replicable, proven classification and intervention system with known treatment utility.

“What was missing from this more qualitative research approach were the experimental methods needed to produce a systematic, replicable, and proven classification and intervention system with known treatment utility.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Clark's cognitive model conceptualized panic attacks as a consequence of catastrophic misinterpretation of bodily sensations such as palpitations and breathlessness.

“Clark’s (1986) model conceptualized panic attacks as a consequence of the catastrophic misinterpretation of certain bodily sensations, such as palpitations and breathlessness.”

• cites Clark, 1986 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Academic psychiatry no longer believes that spending additional billions on protocols for DSM syndromes will be scientifically or clinically progressive.

“Academic psychiatry no longer believes that additional billions spent on “protocols for DSM syndromes” will be scientifically or clinically progressive.”

May combine two claims.

Taken together, the concepts discussed combine to form an extended evolutionary meta-model (EEMM) that can in principle draw process-based work under a single umbrella, providing a functional diagnostic system.

“Taken together, the concepts we have been discussing combine to form an extended evolutionary meta-model (EEMM) -- that can in principle draw process-based work under a single umbrella, providing a kind of functional diagnostic system (Hayes et al., 2019; Hayes, Hofmann, & Ciarrochi, in press).”

• cites Hayes et al., 2019Not checked yet

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• cites Hayes, Hofmann, & Ciarrochi, in pressNot checked yet

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• AssumptionRests on an assumption: The EEMM applies to virtually all known theory-based and empirically well-supported processes of treatment change.

May combine two claims.

RDoC shared with DSM the strong theoretical assumption that latent diseases cause psychological problems and would be identified through research.

“it shared with the DSM the strong theoretical assumption that latent diseases cause psychological problems, and that we would identify these “diseases” through research focused on nonthetic collections.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Behavior therapists incorporated social learning and neo-behavioral associative learning into Skinnerian operant principles to better understand human functioning.

“Behavior therapists soon added ideas drawn from social learning or neo-behavioral associative learning to Skinnerian operant principles in an attempt to understand human functioning (Bandura, 1969; Eysenck, 1961; Wolpe, 1958).”

• cites Bandura, 1969Not checked yet

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• cites Eysenck, 1961Not checked yet

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• cites Wolpe, 1958Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Early CBT focused on maladaptive cognitions as contributors to emotional distress and behavioral problems.

“As a cognitive approach such as was as pioneered by Beck (1970) and Ellis (1962) strengthened, early forms of cognitive behavior therapy (CBT) emerged in which practitioners focused on maladaptive cognitions as contributors to emotional distress and behavioral problems.”

• cites Beck, 1970 sourceNot checked yet

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• cites Ellis, 1962Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

An extended evolutionary approach applies the key concepts of variation, selection, and retention, in context, focused on relevant dimensions and levels.

“We have argued (Hayes, Hofmann, & Wilson, 2020) that an extended evolutionary approach is one that applies the key concepts of variation, selection, and retention, in context, focused on the relevant dimensions and levels.”

• cites Hayes, Hofmann, & Wilson, 2020Not checked yet

  Not checked in the free run.

May combine two claims.

RDoC has limited clinical utility and is intended mainly to advance future research, not yet to guide clinical decisions.

“As is acknowledged by the authors and administrators of the initiative, RDoC has limited clinical utility -- it is primarily intended to advance future research, but is not yet intended as a guide for clinical decision making (Cuthbert & Kozak, 2013; Vaidyanathan et al., in press).”

• cites Cuthbert & Kozak, 2013Not checked yet

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• cites Vaidyanathan et al., in pressNot checked yet

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May combine two claims.

The cognitive model of panic does not rule out biological factors; biological variables may contribute by triggering benign bodily fluctuations or intensifying fearful bodily sensations.

“The model does not rule out any biological factors in panic. Instead, it is assumed that biological variables may contribute to an attack by triggering benign bodily fluctuations or intensifying fearful bodily sensations.”

• cites Clark, 1986 sourceNot checked yet

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May combine two claims.

Panic patients informed about the effects of CO2 inhalation reported less anxiety and fewer catastrophic thoughts than uninformed individuals.

“For example, panic patients who were informed about the effects of CO2 inhalation reported less anxiety and fewer catastrophic thoughts than uninformed individuals (Rapee, Mattick, & Murrell, 1986).”

• cites Rapee, Mattick, & Murrell, 1986 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

RDoC was a step beyond syndromal classification but lacked a comprehensive integrative model and artificially narrowed focus to biological dimensions.

“This was a step forward from syndromal classification, but the RDoC initiative provided no comprehensive model within which to integrate this information and artificially constrained focus to biological dimensions.”

Classified as probably not a substantial claim.

Previous work identified six dimensions of importance at the psychological level: affect, cognition, attention, motivation, self, and overt behavior.

“In previous work (Hayes et al., 2019), we have identified six dimensions of importance at the psychological level: affect, cognition, attention, motivation, self, and overt behavior (See Figure 1).”

• cites Hayes et al., 2019Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Insel resigned as NIMH director, and NIMH's continued commitment to RDoC is highly uncertain.

“Insel eventually resigned as director from NIMH and the continued commitment of NIMH to RDoC is highly uncertain.”

May combine two claims.

Early behavioral approaches used functional analysis from direct contingency principles, but the set of processes they identified was too small to account for human cognition.

“Behaviorists targeted psychological problems based on functional analysis drawn from direct contingency principles. The problem was that these processes formed too small of a set.”

Probably not a substantial claim: may not pass S2 (checkable).

The long era of protocols for syndromes, trademarked therapies, and insular schools is ending and being replaced by a more process-based era.

“It suggests that the decades-long era of protocols for syndromes, trademarked therapies, and insular schools of thought is ending, to be replaced by a more process-based era.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Maslow emphasized an idiographic and process-based approach.

“Maslow (1962) emphasized an idiographic and process-based approach, saying “I must approach a person as an individual unique and peculiar, the sole member of his class” (p. 10).”

• cites Maslow, 1962Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

Any adequate model of change processes should lead to forms of functional analysis that allow practitioners to select treatment elements that will produce better outcomes for individual clients.

“Said in another way, any adequate model of change processes should lead to forms of functional analysis that allow practitioners to select treatment elements that will produce better outcomes for individual clients.”

May combine two claims.

Research using multiple mediator models to explain outcomes of RCTs of ACT shows that psychological flexibility not only mediates outcomes, it statistically eliminates the functional role of the therapeutic relationship in mediating outcomes.

“Research using multiple mediator models to explain outcomes of randomized controlled trials of ACT shows that psychological flexibility not only mediates outcomes, it statistically eliminates the functional role of the therapeutic relationship in mediating outcomes (e.g., Gifford et al., 2011; Walser, Karlin, Trockel, Mazina, & Taylor, 2013).”

• cites Gifford et al., 2011 sourceNot checked yet

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• cites Walser, Karlin, Trockel, Mazina, & Taylor, 2013 sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

Models need philosophical clarity because mixing underlying assumptions incoherently results in analytic confusion and wasted research energy.

“The models need philosophical clarity because if a model mixes its underlying assumptions incoherently, analytic confusion and wasted research energy will result.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

The EEMM provides a systematic framework to consider the potential contribution of any of these dimensions and levels to the particular problem space of an individual.

“The EEMM provides a systematic framework to consider the potential contribution of any of these dimensions and levels to the particular problem space of an individual.”

• AssumptionRests on an assumption: The EEMM applies to virtually all known theory-based and empirically well-supported processes of treatment change.
• AssumptionRests on an assumption: Any aspect of human suffering can be identified and coded in the EEMM.
• AssumptionRests on an assumption: The six psychological dimensions are reasonably comprehensive at the psychological level.
• AssumptionRests on an assumption: The dimensions and levels are highly interconnected.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Concepts within a model are vitalized by consistent connections to other concepts within the model, and unclear or inconsistent assumptions will undermine those connections.

“Concepts within a model are vitalized by their consistent connections to other concepts within the model, and unclear or inconsistent assumptions will undermine those connections.”

Classified as probably not a substantial claim.

The extended evolutionary meta-model provides a meta-theory for intervention-relevant functional analytic models, grounded in evolutionary science, that connects analysis directly to psychological intervention.

“It offers a meta-theory of intervention relevant functional analytic models, rooted in evolutionary science, that directly link analysis to psychological intervention,.”

May combine two claims.

ACT outcomes are consistently mediated by the six primary aspects of psychological flexibility, which line up with the six psychological dimensions of the EEMM.

“ACT outcomes are consistently mediated by the six primary aspects of psychological flexibility, which line up with the six psychological dimensions of the EEMM.”

• AssumptionRests on an assumption: The EEMM applies to virtually all known theory-based and empirically well-supported processes of treatment change.

Probably not a substantial claim: may not pass S3 (load-bearing).

Correlational meta-analytic research suggests that therapeutic alliance has small to moderate associations with therapy outcome.

“Correlational meta-analytic research suggests that alliance has small to moderate associations with therapy outcome (Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012), but its”

• cites Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012 sourceNot checked yet

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Probably not a substantial claim: may not pass S4 (based).

Filling the extended evolutionary meta-model with the change processes proposed by a particular model reduces all of those limitations.

“By populating the EEMM with the processes of change suggested by a specific model, we ameliorate all of these problems.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Evolutionary science will be the foundation of clinical science in the future.

“Evolutionary science is the foundation of the clinical science of the future.”

Probably not a substantial claim: may not pass S2 (checkable).

It is necessary to simplify the list of change processes by theory and evidence.

“It is necessary to simplify the list, by theory and evidence. That is what models do.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

If this idea is correct, therapeutic relationship will be a powerful predictor not because it is the only important mechanism of change, but because it subsumes many other mechanisms of change.

“If this idea is correct, then therapeutic relationship will be a powerful predictor not because it is the only important mechanism of change, but because it subsumes so many other mechanisms of change.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Clinical science has matured enough to adopt evolutionary science principles as its overarching framework.

“The field of clinical science has reached the maturity to embrace evolutionary science principles as its overarching framework.”

Probably not a substantial claim: may not pass S4 (based).

The articles in this special issue demonstrate that evolutionary science principles can supply the consilience required to address highly diverse clinical science questions while preserving useful connections between those questions and the evidence-based answers they produce.

“The articles in this special issue show that these principles can provide the consilience needed to take on extremely diverse clinical science questions, while maintaining helpful linkages between these questions and the evidence-based answers they generate.”

Classified as probably not a substantial claim.

A process-based approach is not just another name for eclecticism because it is necessary to organize processes of change into models that guide their selection and application.

“A process-based approach to clinical practice is not just another name for eclecticism because it is necessary to organize processes of change into models that guide their selection and application (Hayes, Hofmann, & Ciarrochi, 2020).”

• cites Hayes, Hofmann, & Ciarrochi, 2020Not checked yet

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• AssumptionRests on an assumption: A process-based approach is emerging.

Classified as probably not a substantial claim. May combine two claims.

These other processes do not consistently mediate ACT outcomes, and the authors concluded that processes of change in ACT are predominantly linked to components of the psychological flexibility model.

“These other processes do not consistently mediate ACT outcomes and thus the authors concluded that “processes of change in ACT are predominantly linked to the various components of the psychological flexibility model.””

• cites Stockton et al., 2019 sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Viable models of change need to have clear philosophical assumptions; be comprehensive, coherent, and functional; and apply to many, if not most, clients.

“In Hayes, Hofmann, and Ciarrochi (in press) we describe three central features of viable models of change: they need to have clear philosophical assumptions; be comprehensive, coherent, and functional; and apply to many, if not most, clients.”

• cites Hayes, Hofmann, & Ciarrochi, in pressNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

The model must produce positive results across a broad range of clients.

“Finally, the model must produce positive results across a broad range of clients.”

May combine two claims.

Classical functional analysis has three key limitations: it overuses a narrow set of direct contingency principles, cannot specify a reasonably limited set of assessment targets in advance, and has a weak connection to intervention recommendations.

“such as the overuse of a limited set of direct contingency principles, the inability to define a reasonably limited set of assessment targets a priori, and the weak link to intervention recommendations.”

• cites Hayes & Follette, 1992Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

Models themselves need to be shown to have both conceptual and treatment utility.

“Models themselves need to be shown to have both conceptual and treatment utility (Hayes, Nelson, & Jarrett, 1987).”

• cites Hayes, Nelson, & Jarrett, 1987 sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

The dimensions and levels are likely to form complex networks for any individual client.

“Rather, the dimensions and levels are likely to form complex networks for any individual client.”

• AssumptionRests on an assumption: The dimensions and levels are highly interconnected.

May combine two claims.

A strong therapeutic relationship may model, instigate, and support important processes of change, and clients most benefit when they internalize those messages.

“In other words, a strong therapeutic relationship may model, instigate, and support important processes of change and clients most benefit when they internalize those messages.”